The opinion
FILED
Jul 09, 2024
03:32 PM(CT)
TENNESSEE
WORKERS' COMPENSATION
APPEALS BOARD
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
WORKERS’ COMPENSATION APPEALS BOARD
Theralease Ridley ) Docket No. 2022-01-0478
)
v. ) State File No. 47802-2021
)
Mature Care of Standifer Place, LLC, et al. )
)
)
Appeal from the Court of Workers’ ) Heard June 13, 2024,
Compensation Claims ) in Murfreesboro, TN
Audrey A. Headrick, Judge )
Reversed in Part, Modified in Part, and Remanded
In this interlocutory appeal, the employer argues the trial court erred in awarding the
employee a panel of pain management specialists in her new locale. The employee, a
certified nursing assistant, reported an injury after lifting a patient at work. The authorized
physician initially stated the employee’s condition was primarily related to the reported
incident and provided conservative care. Following further diagnostic testing, however,
the physician revised his opinion, stating the employee’s back condition was primarily
related to a pre-existing, degenerative condition and that she had received all necessary
treatment related to the reported work injury. The employee obtained an evaluation from
another physician, who stated the work accident was the primary cause of several disc
herniations and recommended pain management treatment. The employee moved to
another state and requested a panel of specialists, which the employer denied. At an
expedited hearing, the trial court found that the treating physician’s opinion was
inconsistent, determined the causation opinion of the employee’s expert rebutted the
statutory presumption of correctness afforded the opinion of the authorized physician, and
ordered the employer to provide a panel of pain management providers near the employee’s
new residence. The employer has appealed. Upon careful consideration of the record and
the arguments of counsel, we reverse the trial court’s determination that the employee’s
expert rebutted the causation opinion of the panel-selected physician, affirm as modified
the order for the employer to provide a new panel, and remand the case.
Judge Meredith B. Weaver delivered the opinion of the Appeals Board in which Presiding
Judge Timothy W. Conner and Judge Pele I. Godkin joined.
Connor R. Sestak, Nashville, Tennessee, for the employer-appellant, Mature Care of
Standifer Place, LLC
1
Michael A. Wagner, Chattanooga, Tennessee, for the appellee, Theralease Ridley
Factual and Procedural Background
Theralease Ridley (“Employee”) was working for Mature Care of Standifer Place,
LLC (“Employer”), as a certified nursing assistant when she reported pain in her back
beginning on May 22, 2021. She initially obtained medical treatment on her own at
Parkridge Medical Center on May 24, 2021, and, at that visit, she reported a “gradual onset
of symptoms” after lifting heavy patients the week prior. Employee continued to seek
medical care at Parkridge Medical Center on her own before reporting the injury to
Employer on June 11, 2021. When describing the alleged injury, Employee stated that the
morning after she worked on May 22, she woke up “in a lot of pain” in her back, which
she attributed to lifting a heavy patient the day before. Employer’s first report of injury
form does not describe a specific mechanism of injury, but Employee later testified she
experienced pain when moving a 400-pound patient on May 22, 2021.
After Employee gave notice of the alleged incident, Employer provided a panel of
physicians, from which Employee selected Dr. Donald F. Langenbeck, a physical medicine
specialist. 1 Employee first saw Dr. Langenbeck on July 29, 2021, at which time he
diagnosed a lumbar disc protrusion and lumbar radiculitis based on her history, x-rays, and
his examination, and he prescribed physical therapy. Following that initial visit, the
insurance carrier for Employer sent correspondence to Dr. Langenbeck asking if
Employee’s employment contributed more than fifty percent to her “injury/complaints”
considering all causes. Dr. Langenbeck responded in the affirmative and also wrote
Employee “stated that she did not have the pain prior to the work injury.”
Employee returned to Dr. Langenbeck’s office on September 2, 2021, complaining
that physical therapy had made her low back pain worse and that she had returned to the
emergency room a few weeks prior. A physician’s assistant in Dr. Langenbeck’s office
ordered a lumbar MRI and prescribed a lidocaine patch and ketorolac, a non-steroidal anti-
inflammatory drug. The MRI was completed on September 10 and showed bulges at all
disc spaces from L3 to S1. An EMG conducted in January 2022 indicated right L4-L5-S1
radiculopathy. Finally, a January 26, 2022 myelogram with contrast showed degenerative
disc disease with spondylolisthesis, multilevel facet hypertrophy, and partially calcified
extruded discs “at the lower [three] lumbar levels.” On March 10, 2022, after several
steroid injections failed to relieve Employee’s pain, Dr. Langenbeck referred her to his
partner, Dr. Lee Kelley, for a surgical consult and indicated she could return to him “as
needed.” For reasons unclear in the record, Employee saw Dr. Daniel Silcox, another
surgeon in Dr. Langenbeck’s practice, rather than Dr. Kelley. Dr. Silcox noted early grade
1
The panel is not contained in the technical record; thus, we do not know the specialty, if any, of the other
doctors on the panel. Neither party disputes that the panel complied with Tennessee Code Annotated
section 50-6-204(a)(3)(A)(i) (2023).
2
1 spondylolisthesis due to degenerative changes at L4-L5, facet arthropathy, and
preexisting calcified disc bulges at L3-L4, L4-L5, and L5-S1. He informed Employee she
had “significant pre-existing degenerative changes in her spine which were most likely
aggravated by her work injury.” He did not recommend surgery, although he suggested a
radiofrequency ablation of the L4-L5 and L5-S1 facet joints might be indicated.
On May 9, 2022, Dr. Langenbeck responded to another letter from Employer’s
counsel regarding the cause of Employee’s condition and revised his opinion, stating that
the pathology on the CT myelogram of January 2022 pre-existed the May 2021 injury and
that Employee’s condition was not primarily related to the lifting incident at work. Dr.
Langenbeck reiterated this opinion in correspondence dated October 20, 2023. However,
he also signed a “Physician’s Opinion Statement” on October 25, 2023, stating:
It is my considered opinion that this patient did incur a work-related
injury. . . . [Despite] significant pre-existing degenerative changes in her
lumbar spine, . . . her work-related injury . . . was the percipitating [sic]
event that primarily . . . aggravated her pre-existing condition thereby
causing the need for the treatment that she received from me and the need for
a second opinion by Dr. Silcox.
Upon receipt of Dr. Langenbeck’s May 9, 2022 responses to its inquiry, Employer
denied the claim. Employee filed a petition for benefit determination, and the parties
proceeded with discovery. Ultimately, Employee obtained a medical evaluation with Dr.
Stephen Dreskin in October 2023. Dr. Dreskin’s diagnoses were consistent with those of
the other providers, with the exception that he opined the bulges at L3-L4 and L5-S1 had
progressed from bulges to “extruded discs” between the September 2021 MRI and the
January 2022 myelogram. He then stated that “the herniations of L3-L4, L4-L5, and L5-
S1 are all more than 50% primarily caused by [Employee’s] work injury.” He
recommended future medical treatment to include “medical management of her chronic
pain.”
The parties deposed Dr. Langenbeck on February 26, 2024. He described the course
of Employee’s treatment and was questioned extensively regarding his responses to the
questionnaires and other opinions he had expressed. In regard to his opinion on the pre-
existing pathologies, Dr. Langenbeck testified as follows:
[I]t was really based on some developments that came as a result of additional
testing . . . that I did not have on that initial visit of July of ’21. [L]ater on, a
CT myelogram was obtained[,] and it showed some calcifications with some
variations on the disc in her low back. Calcifications would have taken a
long time to develop.
3
Dr. Langenbeck then explained that, in his opinion, the calcifications would have been
present at least six months prior to the work injury, and although his initial belief was that
there was an acute injury at L4-L5 based on the protrusion seen on the initial MRI, the
revelation of the calcifications from the CT myelogram led him to believe the pathology
was “more degenerative” than acute. He testified that, based on the diagnostic testing
obtained to date, he could not say there were any acute changes primarily caused by the
work incident of May 22, 2021. He then reiterated that Employee’s low back condition
was not primarily caused by the lifting incident but was more degenerative in nature.
Dr. Langenbeck further opined that Employee had reached maximum medical
improvement as of March 29, 2022, the last date she treated in his office, stating:
She has completed the whole scope of conservative care. You know, those
aggravations, they oftentimes are -- can settle down within . . . six weeks,
sometimes as long as three months. Universally, . . . three months is the
duration of the inflammatory response.
Regarding future medical treatment, Dr. Langenbeck testified that while pain management
might be helpful for her “accumulated” medical issues, it would not be “part” of her work-
related injury.
The parties did not depose Dr. Dreskin in preparation for the expedited hearing.
Instead, Employee elected to rely on Dr. Dreskin’s written report.
At the expedited hearing on March 1, 2024, Employee was the only live witness.
She testified that she had moved to Bowling Green, Kentucky and that she needed a panel
of doctors for continued medical treatment. She admitted to having daily aches and pains
before the incident at work but asserted that she had been in “severe pain” since that date.
Following the hearing, the trial court determined that Dr. Langenbeck’s testimony
was inconsistent but that Dr. Dreskin’s written opinion was “straightforward” and
“unwavering.” Thus, the court found Dr. Dreskin’s written opinion to be more persuasive
than Dr. Langenbeck’s testimony. It determined Employee was credible and that she had
successfully rebutted the presumption of correctness afforded to Dr. Langenbeck’s
causation opinions. Finally, it found that Employee was likely to prevail at a hearing on
the merits in proving her injury or aggravation of a pre-existing condition primarily arose
out of her employment and ordered Employer to provide a panel of pain management
physicians in Bowling Green, Kentucky. Employer has appealed.
Standard of Review
The standard we apply in reviewing a trial court’s decision presumes the court’s
factual findings are correct unless the preponderance of the evidence is otherwise. See
4
Tenn. Code Ann. § 50-6-239(c)(7) (2023). When the trial judge has had the opportunity
to observe a witness’s demeanor and to hear in-court testimony, we give considerable
deference to factual findings made by the trial court. Madden v. Holland Grp. of Tenn.,
Inc., 277 S.W.3d 896, 898 (Tenn. 2009). However, “[n]o similar deference need be
afforded the trial court’s findings based upon documentary evidence.” Goodman v.
Schwarz Paper Co., No. W2016-02594-SC-R3-WC, 2018 Tenn. LEXIS 8, at *6 (Tenn.
Workers’ Comp. Panel Jan. 18, 2018). Similarly, the interpretation and application of
statutes and regulations are questions of law that are reviewed de novo with no presumption
of correctness afforded the trial court’s conclusions. See Mansell v. Bridgestone Firestone
N. Am. Tire, LLC, 417 S.W.3d 393, 399 (Tenn. 2013). We are also mindful of our
obligation to construe the workers’ compensation statutes “fairly, impartially, and in
accordance with basic principles of statutory construction” and in a way that does not favor
either the employee or the employer. Tenn. Code Ann. § 50-6-116 (2023).
Analysis
Employer raises two central issues on appeal, which we restate as follows: (1)
whether the trial court erred in determining Dr. Langenbeck’s opinion on causation was
successfully rebutted by a preponderance of the evidence, and (2) whether the trial court
erred in awarding Employee a panel of pain management specialists in her new locale.
Employee contends she met her burden of proof and that the order should be affirmed. 2
Presumption of Correctness
As the authorized physician selected from a panel, Dr. Langenbeck’s opinion on
causation is presumed correct, but that presumption can be rebutted by a preponderance of
the evidence. Tenn. Code Ann. § 50-6-102(12)(E) (2023). The trial court determined that
Dr. Langenbeck’s opinion was inconsistent and, thus, found that Dr. Dreskin’s opinion in
his November 14, 2023 report rebutted the presumption afforded Dr. Langenbeck. As we
have previously stated,
2
At oral argument, Employee’s counsel contended Employer’s brief on appeal should not be considered
because it did not comply with the Tennessee Rules of Appellate Procedure. By their own terms, however,
the Tennessee Rules of Appellate Procedure apply to proceedings before the Supreme Court, the Court of
Appeals, and the Court of Criminal Appeals. Tenn. R. App. P. 1 (“These rules shall govern procedure in
proceedings before the Supreme Court, Court of Appeals, and Court of Criminal Appeals.”). Therefore,
we are not governed by these rules, although we may find them instructive. Morgan v. Macy’s, No. 2016-
08-0270, 2016 TN Wrk. Comp. App. Bd. LEXIS 39, at *25 (Tenn. Workers’ Comp. App. Bd. Aug. 31,
2016) (“Although the Tennessee Rules of Appellate Procedure are not binding on us, they are persuasive
authority and we may resort to them for guidance.”); Yarbrough v. Protective Services Co., Inc., No. 2015-
08-0574, 2016 TN Wrk. Comp. App. Bd. LEXIS 3, at *12 (Tenn. Workers’ Comp. App. Bd. Jan. 25, 2016)
(The rules of appellate procedure, “while instructive, do not control the appellate process before this
Board.”). The briefing requirements for the Appeals Board are contained in the regulations governing the
Board, and Employer’s brief complied with those requirements. See Tenn. Comp. R. & Regs. 0800-02-22-
.07 (2023).
5
a reviewing court can review documentary evidence, including expert
depositions, de novo in order to determine where the preponderance of the
evidence lies. However, with respect to the trial court’s ultimate
determination, a reviewing court should acknowledge the trial court’s
discretion to evaluate which expert’s opinion is entitled to greater weight
based on the totality of the evidence presented to the court and is to review
such a determination under an abuse-of-discretion standard.
Johnson v. Inspire Brands d/b/a Blazin Wings, Inc., No. 2020-08-0731, 2022 TN Wrk.
Comp. App. Bd. LEXIS 35, at *18 (Tenn. Workers’ Comp. App. Bd. Sept. 7, 2022). An
abuse of discretion is found if the trial court “applied incorrect legal standards, reached an
illogical conclusion, based its decision on a clearly erroneous assessment of the evidence,
or employ[ed] reasoning that causes an injustice to the complaining party.” Konvalinka v.
Chattanooga-Hamilton Cnty. Hosp. Auth., 249 S.W.3d 346, 358 (Tenn. 2008).
The trial court’s order in this case indicates that Dr. Dreskin’s opinion was “clear
and unwavering.” This assessment is based on a five-page medical report written after a
single evaluation that occurred over two years after the work incident and nearly eighteen
months after active treatment had ended. Dr. Dreskin provided no sworn testimony for the
court’s consideration, and his opinions were not subject to cross examination.
Furthermore, the trial court’s order does not contain any analysis of the qualifications or
experience of each physician or of the relationship of each physician to Employee in
determining that Dr. Dreskin’s causation opinion was more persuasive.
On the other hand, Dr. Langenbeck explained why his causation opinion evolved
over time and why the diagnostic test results led to that change. He explained that the CT
myelogram obtained in January 2022 revealed degenerative calcifications that altered his
opinion regarding the primary cause of Employee’s back condition. Dr. Silcox, who saw
Employee for a surgical consultation, confirmed Employee had a “significant” pre-existing
condition. Dr. Dreskin did not discuss in his report any pre-existing pathology, and he
provided no basis for his opinion that the calcified disc herniations were primarily caused
by the reported work incident. 3
3
Dr. Dreskin identified the pathology seen on the January 2022 myelogram as “extrusions” at L4-L5 and
L5-S1, indicating they had progressed from the bulges seen in the September 2021 MRI. He then referred
to “herniations” at L3-L4, L4-L5, and L5-S1 in opining Employee’s condition was primarily related to the
work incident. However, Dr. Silcox referred to that same pathology as “bulges” in his report, and Dr.
Langenbeck identified them as “protrusions” in his deposition. None of the physicians sought to clarify
these inconsistent descriptions or explain what, in their respective opinions, differentiate disc bulges from
extrusions, protrusions, or herniations. The only testimony pertinent to this issue was from Dr. Langenbeck,
who opined that the presence of calcifications around the lumbar discs supported his opinion that the
condition pre-existed the work accident. Dr. Dreskin’s report is silent as to this issue.
6
Employee argues that Dr. Langenbeck’s definition of an aggravation as stated in his
deposition is inconsistent with Tennessee’s Workers’ Compensation Law. As we have
noted previously, however, medical professionals often use the terms “exacerbation” and
“aggravation” interchangeably. In Miller v. Lowe’s Home Centers, Inc., No. 2015-05-
0158, 2015 TN Wrk. Comp. App. Bd. LEXIS 40 (Tenn. Workers’ Comp. App. Bd. Oct.
21, 2015), we referenced the definition of those terms as stated in the American Medical
Association’s Guides to the Evaluation of Permanent Impairment (“AMA Guides”), which
states:
Although there are circumstances in which an event was the sole or primary
cause of a given effect, in many instances patients have preexisting pathology
that may have contributed to their clinical condition. Aggravation is a
circumstance or event that permanently worsens a preexisting or underlying
condition. The terms exacerbation, recurrence, or flare-up generally imply
worsening of a condition temporarily, which subsequently returns to
baseline. Exacerbation does not equal aggravation.
Id. at *14 (quoting Am. Med. Ass’n, Guides to the Evaluation of Permanent Impairment
25 (6th ed. 2008)). We also acknowledged in Miller that “there is nothing in the statute
indicating that the general assembly relied on the definitions of the terms ‘aggravation’ and
‘exacerbation’ as discussed above.” Id. at *15. Here, we conclude that although Dr.
Langenbeck used the term “aggravation,” his testimony described what the AMA Guides
would classify as an exacerbation. We further conclude that, although Dr. Langenbeck’s
causation opinion evolved over time, his testimony was not inconsistent and took into
account additional objective information provided by diagnostic testing.
We have previously noted that a physician’s failure to provide an opinion using “a
rigid recitation of the statutory definition” does not in and of itself mean the physician’s
causation opinion is legally insufficient. Panzarella v. Amazon.com, Inc., No. 2015-01-
0383, 2017 TN Wrk. Comp. App. Bd. LEXIS 30, at *14 (Tenn. Workers’ Comp. App. Bd.
May 15, 2017). In the present case, when the written opinion of Dr. Dreskin is compared
to the testimony of Dr. Langenbeck, we conclude the trial court abused its discretion in
determining that Employee had rebutted the presumption of correctness attributable to Dr.
Langenbeck’s causation opinion. Accordingly, we conclude the trial court erred in
accepting Dr. Dreskin’s causation opinion over that of the authorized treating physician at
this stage of the case.
Panel of Physicians
Having determined that Employee’s proof did not rebut the presumption of
correctness accorded Dr. Langenbeck’s causation opinion, we must still consider whether
Employee is entitled to a panel of physicians in her new locale. Tennessee Code Annotated
section 50-6-204(a)(3)(F) provides:
7
In all cases when an employee changes the employee’s community of
residence after selection of a physician under this subdivision (a)(3), the
employer shall provide the employee, upon written request, a new panel of
reputable physicians . . . from which the injured employee shall select one
(1) to be the treating physician.
(Emphasis added.) When the term “shall” is used in a statute, “it is ordinarily construed as
being mandatory and not discretionary.” Myers v. Amisub (SFH), Inc., 382 S.W.3d 300,
308 (Tenn. 2012).
As we have noted previously, at an expedited hearing, “an employee need not prove
each and every element of his or her claim by a preponderance of the evidence . . . to be
entitled to [benefits] but must instead present evidence sufficient for the trial court to
conclude that the employee would likely prevail at a hearing on the merits.” McCord v.
Advantage Human Resourcing, No. 2014-06-0063, 2015 TN Wrk. Comp. App. Bd. LEXIS
6, at *9 (Tenn. Workers’ Comp. App. Bd. Mar. 27, 2015). Furthermore, “an aggravation
or exacerbation need not be permanent for an injured worker to qualify for medical
treatment reasonably necessitated by the aggravation.” Miller, 2015 TN Wrk. Comp. App.
Bd. LEXIS 40, at *18. Here, the trial court determined Employee was credible in
describing how the incident occurred, and the authorized treating physician stated that the
treatment he had provided was medically necessary in light of the worsening of her
condition that arose primarily from the incident at work. As such, based on the evidence
presented to date, we do not find any error in the trial court’s determination that Employee
is likely to prove she suffered a compensable accident that entitled her to certain benefits
under the Workers’ Compensation Law, including a panel of physicians. As Employee has
moved to a new community, she is entitled to a new panel of physicians for any medically
necessary treatment causally related to the work accident pursuant to Tennessee Code
Annotated section 50-6-204(a)(3)(F).
We do not, however, find any indication in the record that Employee has established
entitlement to a panel of pain management specialists to treat any condition primarily
caused by the work accident. 4 Dr. Langenbeck opined that the need for pain management
treatment is not causally related to the work accident, and his opinion is entitled to a
presumption of correctness. Dr. Dreskin, in his written report, did not offer an opinion that
the need for pain management treatment arose primarily from the work accident. In fact,
Dr. Dreskin merely stated, “I recommend medical management of the patient’s chronic
pain,” without offering any causative connection between her chronic pain and the work
accident. He then opined that “the patient has reached maximum medical improvement
from a pain management standpoint.” We therefore modify the trial court’s order to require
4
There is no referral for pain management treatment from any authorized treating physician contained in
the technical record. Dr. Dreskin acknowledged in his report that Employee was sent to him for an
independent medical evaluation, not for treatment.
8
Employer to provide a general panel of physicians in her geographic area for treatment of
Employee’s injuries that are causally related to her work accident pursuant to Tennessee
Code Annotated section 50-6-204(a)(3)(A)(i).
Conclusion
For the foregoing reasons, we reverse the trial court’s finding that the presumption
of correctness afforded to Dr. Langenbeck’s causation opinion was successfully rebutted.
We affirm as modified the trial court’s order requiring Employer to provide a panel of
physicians, and we remand the case. Costs on appeal are taxed to Employer.
9
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
WORKERS’ COMPENSATION APPEALS BOARD
Theralease Ridley ) Docket No. 2022-01-0478
)
v. ) State File No. 47802-2021
)
Mature Care of Standifer Place, LLC, et al. )
)
)
Appeal from the Court of Workers’ ) Heard June 13, 2024,
Compensation Claims ) in Murfreesboro, TN
Audrey A. Headrick, Judge )
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the Appeals Board’s decision in the referenced
case was sent to the following recipients by the following methods of service on this the 9th day
of July, 2024.
Name Certified First Class Via Via Sent to:
Mail Mail Fax Email
Connor R. Sestak X csestak@morganakins.com
Nicholas Akins nakins@morganakins.com
plunny@morganakins.com
Michael A. Wagner X maw@wagnerinjury.com
Audrey A. Headrick, Judge X Via Electronic Mail
Kenneth M. Switzer, Chief Judge X Via Electronic Mail
Penny Shrum, Clerk, Court of X penny.patterson-shrum@tn.gov
Workers’ Compensation Claims
Matthew Keene
Acting Clerk, Workers’ Compensation Appeals Board
220 French Landing Dr., Ste. 1-B
Nashville, TN 37243
Telephone: 615-532-1564
Electronic Mail: WCAppeals.Clerk@tn.gov